Dear ISPAD member/friend,

The 2014 ISPAD Clinical Practice Consensus Guidelines were much appreciated. We are happy to announce that preparations for the 2018 Guidelines are now well underway and that a new draft chapter is now ready for your comments and input. We look forward to hearing your thoughts and ideas on the Type 2 Diabetes chapter here below!

Kind regards,

David Maahs

ISPAD Secretary-General 

Thank you for this new chapter, which reads very well. I have a few comments/suggestions:
Initial treatment, 2b-ii

Suggest adding: “When metformin is added to insulin therapy, insulin doses must be deceased considerably (ie by 30-50%) to avoid hypoglycemia.” This is mentioned on p. 17.
HbA1c target: ADA suggests 6.5% [48 mmol/mol] for adults with type 2 diabetes treated with lifestyle or metformin only. Young people will have an even longer diabetes duration than adults, and should therefore in my opinion have the same targets as adults.

p. 24: Albuminuria levels are given in mg/g, while the 2014 complications chapter uses mg/mmol for albumin/creatinine ratio. Needs alignment.

p. 25 The use of statins in sexually active adolescent females must be carefully considered and the risks explicitly discussed, as these drugs are teratogenic and not approved in pregnancy.

I am missing text on acanthosis nigricans. In the clinical context of new-onset diabetes in a country with a low incidence of T2D, AN is a good marker for suspecting T2D and beginning with metformin early, ie before results of autoantibody testing has been received.

Excellent, comprehensive coverage of this topic! 

Some comments and suggestions for the authors' consideration

Page 4 bullet 3

Highlight that this should be a FASTING lipid profile? 3aii (1) states fasting

 

Page 7 2^nd line from bottom of page: typo ethnic/racial

 

Page 8 so as not to offend our Canadian colleagues, include Canadian First Nation youth in the list of high risk populations

 

Page 9 3^rd line from bottom of page typo: autoimmune-mediated T1D

 

Page 9 The most recent report from SEARCH for Diabetes in Youth study indicated that in youth with T2D, DKA at presentation decreased from 11.7% 2002-2003 to 5.7% in 2008-2010. Dabelea, D et al Pediatrics 2014;133(4):e938-45  

 

Page 10 Because measurement of diabetes autoantibodies may not be available or cost may be prohibitive, one us has to rely on clinical criteria. The article by Julia von Oettingen in Pediatric Diabetes 2016;17(6):416-425 provides a simple clinical scoring system (weight Z-score, age and race) that may be useful in these circumstances (low resource settings).

 

Page 11 … as the insulin resistance of puberty wanes

 

Page 24 Indicate whether the goals levels refer to fasting or non-fasting samples… or does it matter? Fasting samples more difficult to obtain in clinical practice. May require patent returning to clinic on another day and this adds to the patient’s burden (inconvenient, cost of travel, time off work, missed school, etc.).

We want to thank all members who provided feedback on the Type 2 Diabetes chapter. 

These comments were used to update the chapter. 

Specific responses are provided in the attached PDF.